Emerald Group Publishing Limited
Copyright © 1999, MCB UP Limited
The Royal Aeronautical Society: Safety in airlines - the management commitment
Keywords Royal Aeronautical Society, Flight safety
The chairmen for the two days of this Conference, Capt W.D. Lowe and Mr L.A. Edwards, the President of the RAeS, introduced the subject and the first paper on the Importance of a Commitment to Safety by the President of the Council of ICAO. He spoke of the fact that ensuring safety in commercial aviation remains as challenging as it has ever been. Despite the impressive achievements in reducing the accident rate, projections for future traffic growth show that considerable resources must be invested to reduce this rate further which has remained virtually unchanged for many years.
Possible avenues to be pursued include the technical solutions adopted to the many problems up to about the mid-1970s which seemed to be approaching the point of diminishing return. Human error seemed capable of circumventing even the best of these. Human factors endeavours became focused on the individual as well as eliminating error through design. More recently, safety concerns were addressed from the organizational perspective and it is suggested that this approach will generate the improvements needed.
The allocation of adequate resources is a fundamental contribution and a major ICAO safety initiative is the Global Aviation Safety Plan (GASP), which is based entirely on an organizational perspective and comprises six major activities including human factors and CFIT. New technologies such as CNS/ATM will be needed as well as fundamental changes in many areas. We must look forward for new safety solutions and not to the past.
Assessment and the consequences of failure
From the University of Texas came a paper on assessing system safety. Flight deck behaviour and flight safety are influenced by the national, organisational, and professional cultures of crewmembers. Natural limitations on human performance and the complexity of the operating environment ensure that error will be an inevitable occurrence. There are positive and negative safety implications of the three cultures to be considered. Effective action to establish a safety culture in an organisation must be based on data regarding the organisation's practices and the threat inherent in the operational context. Multiple sources of data include the Line Operations Safet Audit (LOSA) in which expert observers collect data in the cockpit during normal operations. This information includes external risks and errors, crew errors, and crew actions to mitigate and manage risk and errors. Five types of errors are defined; procedural, communication, proficiency, decision'making, and intentional non-compliance.
The role of Crew Resource Management (CRM) is explored. A significant aspect of LOSA data is the ability to link threat recognition and error management with the specific behavioural markers that form the core of CRM. There are basic steps that every organisation needs to follow to establish a proactive safety culture that is guided by the best possible data on its operations. These include: establish trust; adopt a credible, non-punitive policy towards error (not violation); demonstrate commitment to taking action to reduce error-inducing conditions; collect on-going data that show the nature and types of errors occurring; provide training in threat and error management strategies for crews; and provide training in evaluating and reinforcing threat and error management for instructors and evaluators.
"Safety in airlines - the consequences of failure" was outlined by Airclaims. The director, air safety, began by noting that if there had not been a very great improvement in air safety over the years, the travel industry would not have developed. Even so, the industry has only just succeeded in keeping up with the expansion of air travel. Reducing accident rates is not enough; the actual number of fatal accidents and deaths must be reduced. A number of illustrations showed various statistics and trends over the years. Despite the tremendous growth in air travel over the years, improvements in safety have generally managed to keep up. Fortunately we have seen no increases in the average number of total losses, fatal accident or passenger fatalities for many years (Figure 1). We must not be complacent. With air travel set to double in the next 12 years, great efforts are needed to ensure that the number of fatalities each year do not increase in the future and even greater efforts to reduce the total are required.
Figure 1 Passenger fatalities per million flights
Airbus Industrie contributed its views and began by stating that dialogue is essential for safety. The company has established safety principles which it believes all airlines should implement. Statistics show the percentage of turbojet accidents attributed to the various accident categories. About 10 percent are attributed to technical failure; 5 percent attributed to maintenance; 15 percent to the operating environment such as weather, ATC, or airports; and about 70 percent to flight operations factors.
Failure in human performance is the primary cause of almost all serious accidents; 95 percent of all accidents with Airbus aircraft fall into this category. The best way to reduce accidents is to improve human performance. The Airbus Industrie global safety strategy is based on using modern design concepts and extensive testing; production quality control programmes; continued airworthiness programmes; comprehensive product support programmes; continuous product improvement programmes; feedback on technical and operational events; extensive operator assistance programmes; data sharing; and disseminating (lessons learned). It is evident that automation decreases the accident rate (Figure 2).
Figure 2 Automation decreases accident rate
Airbus Industrie has established various flight safety efforts and the next important step is to encourage operators to establish their own programmes. Most accidents are caused by CFIT; Loss of control in flight; landing short; and off the end of the runway (on takeoff or landing). Reductions in these will make a major impact and Airbus is working towards this.
The chief engineer, aviation system safety, of the Boeing commercial company contributed a paper on accident prevention opportunities for airline safety and reiterated a point that has already been referred to, namely that while the accident rate is low, it has been stable for about the last 20 years. This does vary in diffent regions of the world. With the increases expected in air travel, action must be taken to reduce the overall accident rate.
Experience has shown that manufacturers, operators and governments must work together, as they all have responsibilities to ensure the safety of the industry. Statistics clearly show that CFIT and loss of control in flight are the major contributors to fatalities on a worldwide basis. In terms of hull losses however, landing accidents stand out as the largest contributor, followed by CFIT and loss of control (Figure 3). Based on these two perspectives, the conclusion is reached that CFIT, loss of control and approach and landing accidents account for two thirds of the world's airline fatalities and two thirds of the hull loss accidents. Working to prevent them provides us with the greatest leverage in reducing the worldwide accident rate.
Figure 3 Worldwide airline hull loss accidents
A commitment to safety from senior management is essential together with other key safety programme features. The CFIT training aid, produced by Boeing, has been provided to all customers. Since 1996 the industry has developed the Airplane Upset Recovery Education and Trainig Aid. The recommendations for reducing the number of approach and landing accidents are being implemented. Human factors are at the heart of most, if not all accidents, and various reporting systems enable airline managements to identify and eliminate systemic sources of error. One new program from Boeing is PEAT or the Procedural Event Analysis Tool. The Flight Safety Foundation's "airline management self-audit check list" is useful in determining what makes a "safe" airline safe. We all must work to enhance the safety of operations and by working with others to support system-wide improvements.
Data and safety
British Airways addressed the topic of the use of flight data in airline safety management and concentrated on two aspects: increasing safety by looking for and addressing weaknesses in the operation; and helping management to make sound decisions, as well as monitoring the effectiveness of those decisions. In the past many improvements have come about in response to accidents. Now we need another way to prevent the next accident. Collecting data on the nature, severity and frequency of errors and failures, and then tackling the causes of these; as well as the elimination of potential links in an accident chain, can reduce the chance of the next accident.
Within BA the main FDR (Flight Data Recording) tool is FDE (Flight Data Exceedences)'which is a module of BASIS. All SESMA events are entered into FDE, which can then sort them by nature, severity, location, type, crew member, etc. Areas that need attention are then identitified. An example is the detection of an increasing number of poorly executed approaches, and have subsequently included visual approaches in recurrent simulator training, with the result of a reduction in related events. A number of incorrectly flown go-arounds were also detected, and the simulator training modified accordingly. The whole area of situational awareness in glass cockpits is also being addressed and specific training needs being implemented.
The other area of flight data use is in management decision making and the monitoring of those decisions. An example is GPWS, since while many GPWS warnings were false, pilots were making up their own minds whether to go-around or not. The concept of a "dominant minimum safe altitude" was therefore drawn up and a high compliance rate has been shown. In BA, another FDR tool is MAXVALS, which compares the behaviour patterns of "junior" and "senior" fleets.
Measuring airline safety performance was given by the British Regional Airlines Group. Quality audit activity in both operations and maintenance provides a vital means for monitoring the degree of success of safety management. It helps maintain the foundation for acceptable levels of safety. Quality assurance however, is not enough. While FDR data is a very important part of safety measurement, the overall perspective on reality must come from information voluntarily provided by a wider workforce. "Air safety reports" have to be obtained from all, parts of the company's operational and maintenance community. ASR-based safety management data is entirely complementary to the use of routinely-processed operational FDR data.
An ASR-based system will only be really possible when there is a powerful and sustained corporate commitment to use such disclosure as a means for learning lessons for next time rather than seeking to apportion blame for this time. Key requirements for safety data capture and use are: an independent department free from executive responsibility; an easy-to-use reporting system; an efficient computer-networked event data dissemination and action-recoding tool; complementary reporting systems for flight operations, ground operations, and aircraft maintenance, which lead into integrated actioning; and effective feedback to both individuals and to the reporting community.
The available ASR-database must be likely to fairly reflect reality. Comparative performance assessment must use only ASR events allocated a level of individual safety risk. Overall safety performance can be represented by a plot of monthly means of the intervals between individually significant-risk events. Performance indicators for particular events can be developed and used for safety management.The size of the safety oversight team will be in proportion to the quantity of risk-bearing activity involved. The resources must include operational and technical advisors who are free from executive responsibility for those areas.
The PATS programme
Ansett Australia embarked on a comprehensive review of training course development in 1997, which culminated in the Proficiency Assessment and Training System (PATS). This system is all about accurately determining the need, putting in place the appropriate training programme and measuring the training transfer or result. It is followed by a review, and continual improvement.
Although many of the techniques underpinning the PATS system have been drawn from the FAA's Advanced Qualification Program (AQP), there was no reference to cost savings, any efficiencies gained being a by-product rather than a driver of the approach. Various initiatives led to the development of PATS and the programme now has Phases One, Two and Three, the last two including the further shift towards evaluating system training effectiveness and complete integration of task analysis into training design.
A variety of new processes were introduced by PATS to the Flight Department. An education package was put together to illustrate the training need as opposed to simple regulatory requirements. Ansett has enlarged upon the CRM policy and recognises it as a tool that minimises the impact of error on safe and efficient operations.
The PATS programme was overseen by a steering committee which was kept small but included all major areas. The importance of preparing for change in training design and development cannot be over stressed. Ansett has embraced the proven PATS concept and is now applying it to all aspects of training design. It represents a process rather than a simple product. It is an essential part of an integrated safety, standards and training design system and has successfully delivered significant changes to training and assessment in Ansett.
Cathay Pacific Airways contributed a paper on managing the lessons from new technology which outlined some of the operational lessons learnt as a result of the introduction of new aircraft types during the 1980s and 1990s at the airline in Hong Kong. The arrival of the first Airbus type to be operated by the airline in October 1994, was a significant event. The paper has two objectives. One, to try to provide a balance to the long running extremes of perception which still seem to exist within the man-machine interface; and second, to continue to share the practical lessons which have been learnt at the airline in the last few years.
From October 1994 to May 1999, the airline introduced into service four A340-200 (now returned to lessors), 11 A340-300, 12 A330-200, four B777-200, and five B777-300. Regarding the relationship between automation and pilots, a common need has been that identified over the years for more co-operation between designers and pilots, more responsive and appropriate rule making from regulators, and more appropriate training for new technology. The lessons learnt can be grouped under designers and manufacturers; regulators; and airlines. The "normal law" on Airbus FBW types is quoted, in which the pilot cannot stall, over-stress, over-bank, or over-speed the aircraft. Is this, as industry commentators have suggested, a bad thing? The most precise tool available is utilised - the computer. It is also considered that FBW envelope protection is beneficial in situations which would otherwise involve CFIT accidents. Other instances of design include the continued application of proprietary design "differences" on flight decks where commonality is possible.
For regulators, concerns include the contemporary regulatory awareness of the actual operational environment of the day; the validity of existing regulations in relation to new technology aircraft; and the need for rule-making processes which are responsive to change. For airlines, there is need for adequate preparation for the entry of new technology aircraft; research and design for appropriate crew training; and measurement of system performance and safety, and continuous improvement. In order to collate all sources of performance and safety, Cathay Pacific is introducing an Electronic Reporting and Analysis System (ERAS) to provide more efficient reporting, storage, and analysis of crew and system performance.
Two prominent regional aircraft manufacturers gave papers on aspects of safety enhancement. One, by Embraer was concerned with current flight safety advice programmes, and gave details of how the company is continously working towards safer designs and technology developments as well as continual improvements in all the other areas.
For the EMB-110 Bandeirante over some 25 years of operations, there is strong evidence that 85 percent of these occurred due to operational factors as a result of inadequate operation of the aircraft; problems with safety awareness and indoctrination; and problems with infrastructure. Most of the events occurred in Brazil and the company started a campaign of visits and awareness and pilot training in simulators among operators.
Later, the EMB-120 Brasilia was developed (Figure 4). In 14 years of operation, ten losses have been registered, most due to in-flight loss of control and CFIT. A different behaviour is apparent from the EMB-110 and less loss rate, but still high in less developed areas like Latin America, responsible for 40 percent of the events but less than 7 percent of the accumulated flight hours. The company started a safety awareness campaign to teach new trainees at a very early stage.
Figure 4 EMB-120 Brasilia accident statistics (including minor and substantial damage cases) 1984 to 1998
The advanced EMB-145 regional jet has had two accidents since 1997, one during a training flight, and the other during IMC approach, in both cases the involvement of human factors and operational training programmes being quoted as the main contributing factors. The Embraer Operational Support Programme has had safety returns and has been recently modified to improve communications with the airlines, and has relationships with other bodies. Training programmes with simulators have diminished the number of accidents during training flights and continue to be an effective tool for better pilot training. Operators of the EMB-145 like American Eagle and Continental Express are leading new projects in terms of training programmes development. AQP is referred to as a voluntary alternative to current practice that comprehensively applies instructional technology to air carrier training and checking. Embraer continues to evolve in safety matters although it is recognised that a great number of small operators do need close attention if global safety improvements are envisaged.
The Bombardier approach to safety was described and noted that with the advent of the Canadair Regional Jet in 1991, the company set up and developed training courses not just for mechanics, but in partnership with CAE, developed a ground training and simulator programme for pilots,
Regional airlines are growing rapidly as regards equipment and size. The latest equipment is available such as TCAS, EGPWS, etc. and operators must use all of the tools available. All of the Bombardier training programmes are customized to meet requirements, and it is fair to say that the requirements are exceeded in many cases. All of the company's products either have courses existing or training courses are being developed. Flight training devices and cockpit procedure trainers are available as well as other systems. Emphasis is laid on windshear, CRM, CFIT and human factors. Two incidents are quoted to emphasise that without training or with poor quality training, disaster looms, maybe to a flight crew or ground crew. In day to day aviation, safety depends on the professionalism of the people who manage, maintain and fly aircraft to do their jobs right.